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Eating disorders: the transition years

Fall 2016

Long term eating disorders have a profound effect both physically and mentally, and it is estimated that over a 20 year period approximately 10 per cent of people with anorexia die as a result of health problems or suicide.

Treatment for children and adolescents with eating disorders is distinctly different from treatment for adults. Navigating the transition from adolescent to adult treatment can be extremely difficult for youth.

How is London Health Sciences Centre approaching this critical transition period from adolescence to adulthood, dependence to independence?

Adolescents with an eating disorder who require treatment into adulthood can find themselves suddenly navigating a wholly different health-care system when they legally become adults at 18.

As youth graduate from adolescent treatment, they are thrust into an entirely new role of independence and self-management of their treatment program as adults.

A system-wide issue, there are several intensive hospital programs in the province, including at London Health Sciences Centre, which provide treatment for transition age youth with eating disorders.

At LHSC, those who are in the child and adolescent eating disorder program and require ongoing treatment are eligible to participate in cognitive behavioural therapy for transition aged youth.

The service was started about a year ago.

“The transition aged youth service is intended to offer youth a treatment option that allows them to continue participating in normal age-related activities while receiving treatment for their eating disorder. Although the youth are not required to involve family in the treatment process, they are encouraged to do so,” says Social Worker Lisa Boniferro, who works with transition age youth.

With this model of care the parents are involved but often to a lesser extent than before.

“The child and adolescent team is doing a great job preparing the patients and helping families who struggle with the change. Parents often recognize that their child needs to take on more responsibility but are nervous about the change,” says Dr. Philip Masson, a psychologist with the Adult Eating Disorders Service.

For parents the challenge is letting go, because with the family-based therapy they are used to having the primary responsibility for the youth’s eating, says Boniferro. She always offers to meet with the family at the outset of the transition program and there can be additional family meetings if the youth in the transition wishes.

“If the youth lives with their family you have to navigate that well. In the family session we talk about how to help increase what they are doing well and how to decrease what is not working so well. It is tough for the family to watch their loved one struggle and not play such an active role in change.”

Boniferro and Dr. Masson are looking at better integrating the move of youth from adolescent treatment to the transition age program.

“We are also looking at outcomes and collecting data over time,” says Dr. Masson. “We hope to compare our outcomes to similar programs in Ontario to ensure we are providing the best care possible.”

Treating transition age youth

The transition age youth service at LHSC is a structured 20-week cognitive behavioral therapy treatment that is goal oriented. The sessions are one-on-one, and take a phased approached to treatment.

For the first five weeks of the program the patient receives two 50 minutes sessions a week.

“This is our opportunity to get to know each other, determine what their symptoms are, orient them to a new model of treatment, and explain how the treatment will progress,” says Boniferro.

Although many patients have a preoccupation with food which leads them to know a lot about cooking, they often struggle to eat what they cook. In the session, sample meal plans and guidance are provided regarding practical things for them to make.

“Youth plan their meals to contain any food they wish, as long as they don’t compensate after (e.g. exercise, fast, or vomit)” she says. “We are trying to normalize eating and this can’t be achieved if compensatory behaviours are present.”

The next phase in treatment consists of nine weekly sessions focused on improving body image once their eating is normalized.

“We have to address the things that maintain the eating disorder mindset. With eating disorders, poor body image is typically experienced intensely and it is impairing. Many also have very rigid food rules,” says Boniferro.

Food rules can vary. For example, one person may have a rule that they can only have 60 per cent of the food that their parents put on the plate. Another may have a chocolate bar but only if they eat nothing but vegetables for the rest of the day.

“Participants identify their food rules and we intentionally break them by placing foods in their meal plans.”

Participants keep a detailed record of what they are eating and when, as well as their thoughts and feelings. There is always a formal review of the eating diaries in session with the patient to assess how they’re doing and keep both therapist and participant focused on treatment goals.

In the last phase, the sessions are held every two weeks and focus on relapse prevention strategies.

“Everyone has stressors come up, such as school and difficult relationships, and we need to make sure people know what to expect and how to address it without reverting back to the eating disorder behaviours,” says Boniferro.

She also meets with the patient 20 weeks after the last session to see how they are doing and review the relapse prevention plan. They can also add booster sessions, if needed.

Provincial network

The Ontario Community Outreach Program for Eating Disorders (OCOPED), which is funded by the Ontario Ministry of Health and Long-Term Care, works collaboratively with a provincial network of specialized eating disorder service providers.

It is a challenge to provide continuity of care, to bridge the paediatric system to the adult system in a way that is seamless for a particularly vulnerable age group in terms of mental health, says Dr. Amrita Ghai, Clinical Psychologist and an OCOPED member, who implemented the transition age youth program in the Eating Disorders Outpatient Clinic at St. Joseph’s Healthcare in Hamilton two years ago and also provides private eating disorder treatment at The Clinic on Dupont in Toronto.

In addition, patients in this age group are often in the midst of pursuing post-secondary education.

“How do we facilitate youth going away to university in another city while in the midst of a treatment program? The practicality of making plans to continue treatment when they move to another city for schooling are unique to transition age youth,” says Dr. Ghai.

At this point the use of tools such as the Ontario Telemedicine Network (videoconferencing) is not that common, and the future may also bring other modifications to make treatment more accessible to youth, such as texting appointment reminders and online completion of food records.

“Through collaborative efforts we are attempting to develop consistency in treatment elements and program evaluation,” says Dr. Ghai. “We are also attempting to share resources and learnings from the multidisciplinary OCOPED members in order to optimize treatment for this vulnerable group.”

The Child and Adolescent Eating Disorder Program at LHSC provides clinical services for children and youth up to 18 years of age. This multidisciplinary team consists of a psychiatrist, pediatrician, psychologist, dietitian, social worker, nurse case manager, and child and youth workers.

After an initial assessment with the team, the patient and family receive treatment in one of three areas – outpatient, day treatment, or inpatient.

Outpatient services offer family-based treatment known as the Maudsley Approach.

In the day treatment program, patients are involved with group therapy, individual therapy, family therapy, and meal support.

The inpatient service provides more intensive support. In addition to the treatment team, patients and families are also supported by inpatient nurses and child and youth workers.

In the Adult Eating Disorders Service at LHSC, most adults with eating disorders participate in an eight to 12-week day treatment service. This service is run in collaboration with the Canadian Mental Health Association.

Participants work with a multidisciplinary team and participate in a wide range of group programming, following a cognitive behavioural therapy (CBT) approach. The aim of treatment is to normalize eating, stop eating disorder related behaviours, facilitate weight restoration as needed, and improve participants’ quality of life.

There is also a residence for adults who require additional support with their eating disorder.

54 Riverview Avenue: LHSC’s Adult Eating Disorders Service has new home in the community

In April 2016, staff and patients of LHSC’s Adult Eating Disorders Service moved into their new home at 54 Riverview Avenue.

LHSC is the first hospital in Ontario working in partnership with the Canadian Mental Health Association Middlesex to offer a community-based residential eating disorders program.

The new facility allows patients of the program to receive their treatment under one roof, and has a capacity of eight beds in the residential treatment program, for those requiring intensive support.

“Moving into this new space in the community allows us to significantly increase the number of patients we are able to see and expand the care we are able to provide,” says Dr. Philip Masson, program psychologist.

“We are now able to work with patients in our new teaching kitchen and provide treatment in brand new group rooms. The eight-bed residence will allow us to provide short-term residential treatment stays to help patients interrupt their symptoms, a much needed treatment option. I also believe that the home-like environment will help patients feel comfortable throughout their treatment.”

Community Support of the Adult Eating Disorders Service

London Health Sciences Foundation would like to extend its sincere thank you to donors for their generous support and compassion. Donors have changed the lives of patients and families with their support. Eating disorders are the single most deadly mental illness and donors understand this and have played a critical role in helping patients access programs in a facility tailor-made for their care.

"Our patients with eating disorders often have significant shame and guilt about their disorder. Contributions from donors have a tremendous impact by not only helping us offer treatment in a wonderfully equipped facility but also by signifying to our patients that our whole community validates their struggle and is supporting them in their treatment,” says Dr. Philip Masson, Psychologist, Adult Eating Disorders Service, LHSC.

Donor support enhances and strengthens the continuity of care for patients with mental health disorders in London and Southwestern Ontario. Donors are making it possible for our hospital to introduce new programs and augment existing ones designed to intervene at the earliest signs of mental health difficulties. Learn more at www.lhsf.ca.